202205-3141-001CF RCF OMB: 3206-0277
OMB.report
OMB 3206-0277
RCF 202205-3141-001CF
( RCF Recertification )
Array
(
[refNbr] => 202205-3141-001CF
[obm] => 3206-0277
[icr] => 202202-3206-002
[status] => Active
[agency] => NIGC
[title] => Certification of Vaccine Form (NIGC)
[typeRCF] => RCF Recertification
[oiraAction] => Approved
[oiraNOA] => 420280
[termsOfClearance] =>
[previousRCF] => 202108-3141-003CF
[agencyTrackingNo] =>
[conclusionDate] => 2022-05-24
[dateReceived] => 2022-05-24
)
Document
View RCF
- OIRA Conclusion
RCF ID: 202205-3141-001CFPrevious RCF ID: 202108-3141-003CF
Status:
Active
Expiration Date: 05/31/2025
Agency/Subagency: NIGCAgency Tracking No:
Host OMB Control No: 3206-0277Host ICR Reference No: 202202-3206-002
Title: Certification of Vaccine Form (NIGC)
Type of RCF: RCF Recertification
OIRA Conclusion Action: ApprovedConclusion Date:
05/24/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/24/2022
Terms of Clearance:
Description of Agency Usage:
The NIGC will use this form to prevent the spread of COVID-19 and to
protect the health and safety of all Federal employees, onsite contractors,
visitors to Federal buildings or Federally controlled indoor workspaces, and
other individuals interacting with the Federal workforce.
Authorizing Statute(s):
EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
5 USC Chapters 11 and 79
Annual Cost to Federal Government:
Agency Contact:
Tim Osumi 202 632-7054 [email protected]
Common Form Information Collections (IC) in this RCF:
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Certification of Vaccination Common Form
100
3
90
Form and Instruction
OPM 5062
Certification Vaccination Employee
Form and Instruction
CV2
Certification of Vaccination Common Form
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
100
100
0
0
0
0
Annual Time Burden (Hours)
3
3
0
0
0
0
Annual Cost Burden (Dollars)
90
81
0
0
9
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement: